Perioperative point-of-care-testing of plasmacholinesterases identifies older patients at risk for postoperative delirium: an observational prospective cohort study.

BACKGROUND: Postoperative delirium (POD) is a severe perioperative complication that may increase mortality and length-of-stay in older patients. Moreover, POD is a major economic burden to any healthcare system. An altered expression of Acetylcholine- and Butyrylcholinesterases (AChE, BuChE) due to an unbalanced neuroinflammatory response to trauma or an operative stimulus has been reported to play an essential role in the development of POD. We investigated if perioperative measurement of cholinesterases (ChEs) can help identifying patients at risk for the occurrence of POD in both, scheduled and emergency surgery patients. METHODS: This monocentric prospective observational cohort study was performed in a tertiary hospital (departments of orthopaedic surgery and traumatology). One hundred and fifty-one patients aged above 75 years were enrolled for scheduled (n = 76) or trauma-related surgery (n = 75). Exclusion criteria were diagnosed dementia and anticholinergic medication. Plasma samples taken pre- and postoperatively were analysed regarding AChE and BuChE activity. Furthermore, perioperative assessment using different cognitive tests was performed. The type of anaesthesia (general vs. spinal anaesthesia) was analysed. Primary outcome was the incidence of POD assessed by the approved Confusion Assessment Method (CAM) in combination with the expression of AChE and BuChE. RESULTS: Of 151 patients included, 38 (25.2%) suffered from POD; 11 (14%) in scheduled and 27 (36%) in emergency patients. AChE levels showed no difference throughout groups or time course. Trauma patients had lower BuChE levels prior to surgery than scheduled patients (p < 0.001). Decline in BuChE levels correlated positively with the incidence of POD (1669 vs. 1175 U/l; p < 0.001). Emergency patients with BuChE levels below 1556 U/L were at highest risk for POD. There were no differences regarding length of stay between groups or incidence of POD. The type of anaesthesia had no influence regarding the incidence of POD. Only Charlson Comorbidity Index and Mini Nutrition Assessment demonstrated reliable strength in respect of POD. CONCLUSIONS: Perioperative measurement of BuChE activity can be used as a tool to identify patients at risk of POD. As a point-of-care test, quick results may alter the patients' course prior to the development of POD. TRIAL REGISTRATION: https://drks.de/search/de/trial/DRKS00017178 .

[Perioperative patient blood management in the aged-more than only transfusion? : Review of the 4th symposium of the working group on anemia on the occasion of the annual meeting of the German Geriatric Society in Frankfurt 2019]. / Perioperatives Patient Blood Management im Alter ­ mehr als nur Konservengabe? : Zusammenfassung des 4. Symposiums der AG Anämie anlässlich der Jahrestagung der Deutschen Gesellschaft für Geriatrie in Frankfurt 2019.

Anemia is frequent in older people with one in two geriatric inpatients being affected. Therefore, in elective surgery, such as endoprosthetic treatment it is very likely that anemia is already present in a preoperative setting. So far there are no particular guidelines about perioperative management of anemia in geriatric patients. The existing recommendations of the Patient Blood Management (PBM) network cooperation and the current Association of the Scientific Medical Societies in Germany (AWMF) S3 guidelines on preoperative anemia refer to all patients aged >18 years but without particular consideration of the growing number of oldest old orthogeriatric patients. This is more problematic as anemia in the aged has been shown to be different from anemia in younger patients in terms of diagnostics and treatment. Based on several interdisciplinary lectures, this year the symposium of the working group on anemia of the German Geriatric Society (DGG) focused on the problems of perioperative PBM in orthogeriatric patients and encouraged the discussion about developing PBM treatment recommendations for this patient group.

Machine Learning to Detect Alzheimer's Disease from Circulating Non-coding RNAs.

Blood-borne small non-coding (sncRNAs) are among the prominent candidates for blood-based diagnostic tests. Often, high-throughput approaches are applied to discover biomarker signatures. These have to be validated in larger cohorts and evaluated by adequate statistical learning approaches. Previously, we published high-throughput sequencing based microRNA (miRNA) signatures in Alzheimer's disease (AD) patients in the United States (US) and Germany. Here, we determined abundance levels of 21 known circulating miRNAs in 465 individuals encompassing AD patients and controls by RT-qPCR. We computed models to assess the relation between miRNA expression and phenotypes, gender, age, or disease severity (Mini-Mental State Examination; MMSE). Of the 21 miRNAs, expression levels of 20 miRNAs were consistently de-regulated in the US and German cohorts. 18 miRNAs were significantly correlated with neurodegeneration (Benjamini-Hochberg adjusted P < 0.05) with highest significance for miR-532-5p (Benjamini-Hochberg adjusted P = 4.8 × 10-30). Machine learning models reached an area under the curve (AUC) value of 87.6% in differentiating AD patients from controls. Further, ten miRNAs were significantly correlated with MMSE, in particular miR-26a/26b-5p (adjusted P = 0.0002). Interestingly, the miRNAs with lower abundance in AD were enriched in monocytes and T-helper cells, while those up-regulated in AD were enriched in serum, exosomes, cytotoxic t-cells, and B-cells. Our study represents the next important step in translational research for a miRNA-based AD test.

[Prevention of delirium in the intensive care unit]. / Prävention des Delirs auf der Intensivstation.

A delirium in patients in the intensive care unit (ICU) is a manifestation of a severe acute dysfunction of the brain. It has a high prevalence and is associated with a relevant increase in morbidity and mortality. A cholinergic deficit and dopaminergic overactivity are considered to be a cause of delirium. Polypharmacy, which is often present before admission to the ICU, especially in the elderly, plays a key role as a trigger. The knowledge and identification of risk factors for delirium is a precondition for the early and effective prevention of delirium. The aim is the pre-operative or pre-interventional optimization of modifiable risk factors. Early and effective prevention of delirium can improve clinical outcome, reduce mortality, and positively impact long-term functional outcome. Non-pharmacological measures are always the basis for the prevention of delirium: maintenance of the day-night rhythm, sleep promotion at night and stimulation during the day, involvement of relatives, the avoidance of dehydration and malnutrition, and others more. They are pharmacologically accompanied by an effective analgesia and a target and symptom-oriented sedation with well controllable, as little as possible delirogenic substances. Interdisciplinary and interprofessional cooperation is essential so that preventive concepts significantly reduce the risk of delirium, even in high-risk patients.

[The geriatric syndrome of anemia-Summary of the symposium of the working group anemia during the annual meeting of the German Geriatric Society 2018 in Cologne, Germany]. / Anämie als geriatrisches Syndrom ­ Zusammenfassung des Symposiums der AG Anämie anlässlich der Jahrestagung der Deutschen Gesellschaft für Geriatrie 2018 in Köln.

This year's symposium of the working group anemia of the German Geriatric Society (DGG) aimed to underline the multicausality of anemia in the aged and to highlight definition parallels with geriatric syndromes. For these reasons, nutritional and malignant causes for anemia were discussed and the influence of oxidative stress on the development of anemia was underlined. The need for ongoing research in the field of anemia in the aged was emphasized by the lack of perioperative transfusion strategies in geriatric patients.

Prehabilitation is better than cure.

PURPOSE OF REVIEW: With a continuously growing number of older patients undergoing major surgical procedures, reliable parameters practicable in perioperative routine revealing those patients at risk are urgently needed. Recently, the concept of 'prehabilitation' with its key elements exercise, nutrition and psychological stress reduction especially in frail patients is attracting increasing attention. RECENT FINDINGS: Literature search revealed a huge amount of publications in particular within the last 12 months. Although a single definition of both frailty and prehabilitation is still to be made, various players in the perioperative setting obviously are becoming increasingly convinced about a possible benefit of the program - referring to different components and measures performed. Although physiologically advantages seem obvious, there is hardly any reliable data on clinical outcomes resulting from properly performed studies. This applies especially to octogenarians; thus those at risk for adverse events the concept originally addresses. SUMMARY: Identifying high-risk patients at the earliest possible stage and increasing their physiological reserve prior to surgery is a promising approach that seems to result in remarkable improvements for older patients. However, further studies on effectiveness in a highly heterogeneous population and agreement on a common concept are mandatory before a final judgement can be given.

[Preoperative risk identification using the Identification of Seniors at Risk? : Suitability as sole screening tool for inpatient aged risk patients]. / Präoperative Identifikation mithilfe des Identification of Seniors at Risk? : Eignung als alleiniges Screeningtool für stationäre hochaltrige Risikopatienten.

BACKGROUND: As more aged patients are surgically treated in hospitals without specialized geriatric care, patients at risk for perioperative complications must be identified and treatment must be adapted. The aim was the use of the Identification of Seniors at Risk (ISAR) as a screening tool for the identification of high-risk patients, who need specialized perioperative care. The study presented investigated the use of ISAR screening not only as recommended in the emergency room but also in validation tests as a new option in elective surgery. MATERIAL AND METHODS: Routine data recorded during inpatient admission of 389 patients were evaluated retrospectively. The ISAR as well as a cognitive screening with the mini mental state examination (MMSE) were conducted in patients as long as a previously diagnosed dementia was not present. Delirium was recorded using the Confusion Assessment Method (CAM). A total of 88 patients from trauma surgery served as an example for emergency surgery and 93 patients from orthopedics for elective surgery. All patients received treatment by the department of Anesthetic and Perioperative Geriatric Care. RESULTS: According to an ISAR score of ≥2 points, 85.2% of traumatology and 48.4% of elective orthopedic patients were considered to be geriatric high-risk patients. Among ISAR negative patients many suffered from preoperative cognitive decline (MMST or diagnosed dementia), especially in the elective orthopedics group. Delirium occurred in 5.7% of trauma surgery patients and in 4.3% of elective orthopedic patients. CONCLUSION: With 2 as a cut-off, the use of ISAR as a screening tool was only conditionally suitable. In particular, the expected filter function was not fulfilled in both groups.

Intra- versus postoperative initiation of pain control via a thoracic epidural catheter for lumbar spinal fusion surgery.

BACKGROUND: Thoracic epidural anesthesia (TEA) is one of the pillars of perioperative pain care. Particularly for spine surgery which causes significant postoperative pain TEA seems like an appealing option. However, beneficial effects of a TEA are questionable when the catheter is not used intraoperatively, a decision that is usually based on the surgeon's wish to perform immediate neurological examination postoperatively. METHODS: Forty patients undergoing transforaminal lumbar interbody fusion surgery (TLIF) were randomized into two groups. Patients received preoperative insertion of a TEA. For patients in the intraoperative group an epidural infusion was started preoperatively and maintained throughout. For patients in the postoperative group the epidural infusion was started once neurological examination had been performed. The primary outcome measure in this study was postoperative requirements of piritramide during the first two postoperative hours. Secondary outcomes involved postoperative pain numeric rating scale (NRS) scores, intraoperative opioid requirements, side effects and ability to perform direct postoperative neurological examination. RESULTS: Postoperative group patients required significantly more opioids both intra- and postoperatively (P=0.036 and P=0.039) and NRS scores were significantly higher on admission to recovery, at 30 and 60 min as compared to patients in the intraoperative group (P=0.013; P=0.004 and P=0.012). Early postoperative neurological examination was feasible in all patients in both groups. CONCLUSIONS: Epidural catheters used intraoperatively during TLIF are feasible, significantly reduce pain, intra- and postoperative use of opioids and do not influence the quality of neurological tests directly after the surgical procedure.

[Preoperative Evaluation and Arrangements: The Elderly Patient]. / Präoperative Vorbereitung und Evaluation: der ältere Patient.

With a constantly growing portion of elderly within our population and the advances of modern medicine, surgery on aged and very aged patients has become a daily hospital routine. Due to the physical and mental features of ageing these patients face special perioperative risks. They display a higher rate of complications, morbidity and cognitive deficits which might in the end lead to persisting need of care. Even in the healthy elderly, most organ functions are "physiologically" instable or deficient and the homeostasis of health and disease is fragile. The preoperative evaluation of the aged patient has to be extended towards risk factors and pathologic pre-conditions which derive especially from high age and are so far not determined by a mere "fit-for-anaesthesia?" EVALUATION: This includes assessment of frailty and functional status as well as the evaluation of pre-existing cognitive deficits, malnutrition and polypharmacy. Prevention of postoperative cognitive deficits and delirium is an important goal of medical therapy and requires i. a. omission of benzodiazepines, BIS-controlled anaesthesia, focus on patient's comfort and orientation and inclusion of close relatives and confidants in all processes. Considering all this, an elderly patient might require more time than usually given to be well prepared for anaesthesia, surgery and the postoperative course. The altered physiology and the special risk profile of the aged patient demand special attention and time throughout the perioperative phase. With an increasing number of elderly presenting for surgery, it is likely that more age-adapted structures and processes become implemented in our hospitals.

How to prevent perioperative delirium in the elderly?

Due to increasing life expectancy, the number of elderly patients needing surgical care is increasing. Improvements in surgical techniques and anesthetic procedures offer the opportunity of surgical intervention even in frail patients. Delirium on admission to the hospital or in the perioperative setting is a common and often serious complication. Cognitive impairment is regarded as the main risk factor for delirium; unfortunately, under routine clinical conditions, these deficits often remain undetected. Postoperative delirium is associated with increased morbidity and mortality, as well as increased length of hospitalization, resulting in increased suffering and costs. The aim of the intervention presented here was to prevent delirium in a general hospital without a geriatric specialty department. Geriatric nurses became part of the team in the perioperative setting, giving psychological support and being a continuous companion to the patient and his/her proxies. Co-operation between all professions involved throughout hospitalization of the patient was emphasized. The low incidence of delirium in elderly surgical patients resulting from our efforts indicate that - for this setting in a general hospital - the strategy was effective for the prevention of delirium. Nowadays, geriatric nurses are an essential part of the perioperative team and delirium has lost much of its imminence.